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Thrombocytopenia In Intensive
Care – Causes and Investigations
Lau Ngee Siang
Hospital Ampang
Conflict of Interest!
• NONE!
Medscape
• Disseminated Intravascular Coagulation
Treatment & Management
• Author: Marcel M Levi, MD; Chief Editor:
Emmanuel C Besa, MD more...
• Overview
• Presentation
• DDx
• Workup
• Treatment
• Medication
MEDSCAPE EDUCATION
• Guidelines for Managing Thrombocytopenia in
the ICU CME
• News Author: Emma Hitt, PhD
CME Author: Charles P. Vega, MD
Definition
• < 150 X 109/L.
• Severe <50
• Less 30% from baseline????
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Multifactorial
Critically ill – marker of severity
Higher MODS/APACHE score
Inverse correlation with mortality and
prolonged ICU stay.
• D4 thrombocytopenia correlates with further
severity? (some trials data)
Dynamics of Platelets in ICU
• Most Reducing, D1-D4 (Nadir) – post-op eg:
Cardiac/Maj Trauma/Abd Surgery/Vasc
Surg/Maj Orth Surg.
• >D4 increasing 2-3X of baseline (REBOUND)
and peak D14!
• ***Intact Physiologic response to PLTs
consumption! By MEGAKARYOCYTES!
• Acute Consumption - Reduced PLTs –
Increased Thrombopoietin –
Megakaryocytosis – D3 start to release PLTs
>D4 Thrombocytopenia post Surg
• D4 thrombocytopenia mortality 33%
• D14 thrombocytopenia mortality 66%
• Post cardiac surg ICU: Mortality for D4
increasing PLT 1.3% VS D4 PLT<100 12%
• >D4 need to determine cause: Infection,
drug,…
Management of Post-Surg Low PLTS
• PLT >50/No Bleeding: Watch only!
• On presentation: PLT 50 – 100 with
GIT/Retroperitoneal haemorrhage/Acute
trauma/Surgery: Loss/Consumption of PLTS!
• Need intervention & try keep PLTs >80-100
• Hematocrit >30%
• Tranexamic Acid 1g slow bolus and 1g infusion
over 8 hours for trauma case (Lancet
2010)???? Thrombosis risk????
Medical ICU Thrombocytopenia
• D3 40% <150
• D5 90% <150
• Important to determine cause to treat/manage
appropriately
• General rules:
• 5-7 days slow & gradual: consumptive
coagulopathy/marrow failure
• 1-2 days Abrupt: Immunologic causes/ drug
induced immune thrombocytopenia/adverse
transfusion reaction (post-transfusion
purpura/passive allo-immunization)
?Medical dynamic
Medical Low PLTs
• Most common cause:???? YOU KNOW!!!!!
• PLTs < 50, DIC is frequently present!
• Worseing PLT count – worsening underlying
disease – MOF & Consumptive Coagulopathy
DIC – Clinical & Lab Definition
Thrombosis & Thrombocytopenia
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Mostly moderate thrombocytopenia
Severe PE
TTP/HUS
Catastrophic APS (venous & arterial)
HIT (if Heparin within last 10 days)
DKA (arterial)
PLT<20
• What’s next?
• Consider the cause (Marrow failure, PE, TTP,
ITP, Sepsis)
• KIV Urgent FBP!!!
• Pseudothrombocytopenia! (GPIIb/IIIa inhibitor
inducerd?)
• Give PLTs: May be diagnostic
• If marrow failure: PLTs ++. If immunemediated PLTs_____. (1 hour post)
Important Thrombocytopenia causes
• TTP – PE
• ITP
• HIT – Related to Anti PF4-Heparin Complexes.
Use Direct Thrombin Inhibitor (Lepirudin,
Argatroban) or Heparanoid (Danaparoid)
TTP blood film
J Suriar 2012
PLT<20
• New rapid (after D4): Often immune
mediated (Refer Chart)
• GP Ilb/llla inhibitor in cardiac (within 10days)
• Drug dependant (10 days)
• Transfused BACTERIA contaminated product:
PLT>PC>FFP
• Post transfusion purpura (rare)
• Transfusion induced alloimmune low PLT
Case Study
• A Splenic Marginal Zone Lymphoma with bulky
splenomegaly, failed chemotherapy (R-CHOP
& RICE). - Marrow: Infiltration, relatively
preserved haemopoiesis.
• Proposed splenectomy! Main bulk of disease!
• Intro-op: Bleeding: 5L Blood loss! DIC. PLT
post transfusions 30-50. Second look Surgery:
2L blood clots! (Pre-op PLT 80-100)
• Prolonged PT/APTT & low fibrinogen.
Management of DIC
• Treat the underlying cause
• Stabalize haemodynamically
• Manage clinically with the assistance of
laboratory support
• Blood product as per necessary
Role of antifibrinolytic
Thank You